INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 6, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Turning Point II was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection.
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Plan of Correction
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records, CPR and first aid certification cards, the facility failed to ensure that a sufficient number of staff persons were trained in CPR.The findings include:Two personnel records and employee CPR and first aid certification cards were reviewed on August 6, 2013. None of the employees had the required CPR certification. The facility failed to ensure that a sufficient number of staff persons were trained in CPR.The project/facility director and Administrative Officer were interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Project Director shall locate, schedule and oversee the successful completion of a hands-on CPR recertification course for identified staff by 9/30/2013. Thereafter, Project Director shall review semi-annually staff CPR training to insure current certification to provide adequate coverage at all times. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill records, the facility failed to maintain a written fire drill record including the number of persons in the facility at the time of the drill and the problems encountered.The findings include:Fire drill records were reviewed for the time period of August 2012 through July 2013 on August 6, 2013. The fire drill records did not include the number of persons in the facility at the time of the drill and the problems encountered for the following fire drills: July 19, 2013, June 13, 2013, May 15, 2013, April 16, 2013 and March 22, 2013.The Administrative Officer was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Project Director has adjusted the format of the Fire Drill Record to include the date, time, evacuation time, egress route, number of persons participating, problems encountered and validation of smoke detector operation. Project Director shall review Fire Drill Records monthly to insure complete documentation of mandated entries. |